Saturday, November 1, 2014

Progressive Arguments to Consider for Midterm Voters

A hallmark of progressive politics is the ability to hold fervent beliefs, in defiance of evidence, that explain how the world works – and why liberal solutions must be adopted.

Kate Bachelder. Assistant editorial features editor at the Wall Street Journal, “The Top 10 Liberal Superstitions," Wall Street Journal, October 31, 2014

In considering how to vote on November 4, there are multiple progressive arguments to weigh - among them, the overall competence of the Obama administration and the arguments advanced by its advocates as reasons for voting for the progressive Democratic agenda.

Among these cherished arguments, the truth of the following assertions must be weighed against the evidence.

1) Spending more money improves education - Not in the U.S. if you consider U.S. student test scores compared to other nations who spend far less.

2) Government spending stimulates the economy - Not if you consider the sluggish 2.2% growth since 2008, the worst recovery since World War II, in spite of the 2009 $838 billion stimulus package.

3) Republican always have a spending advantage over Democrats - There is no evidence of this. In fact, the opposite is true if take into account spending by the Democrat ($127 million)and the GOP national committees ($97 milion).

4) Raising the minimum wage helps the poor
- Not for the poor as a whole, who will lose 500,000 jobs, and only 18% of which would flow to those below the poverty line.

5) Global warming is causing increasingly violent weather
– Not for Floridians, who haven’t had a hurricane hit land in the last nine years, and who enjoyed the least active hurricane in 30 years.

6) Genetically modified food is dangerous - There is not a smidgen of evidence to support this claim.

7) Voter ID-laws suppress minority turnou – Not necessarily so. 30 states have voter-ID laws, 16 offer free IDs, The Government Accountability Office studies 10 of these states show- five had not effect, four showed a slight decrease in turnout among all ethic groups, and one found an increase in turnout.

8) ObamaCare is increasing in popularity - Not for the public at large, which is the latest CBC/WSJ polls oppose the ACA by a record 19 points (55% to 36%), or among physicians.ess than 4% give ObmaCare an “A” while 46% give it a “D” or an “F”.

9) The Keystone XL pipeline would increase oil spills. Not if you consider the alternative – shipping oil by train. In 2013, pipelines spilled 910, 000 million gallons while railroad tankers spilled 1.5 million, even though pipelinrs carried 25 times more oil.

10) Women are paid 77 cents on the dollar compared to men. Not if you compare full-time men workers to full-time women workers. When this is done, the pay-gap disappears.

I believe, three days hence on November 4, Republicans will win big, not because of their superior values or because they articulate those values well, but because the ten superstitions described above are insufficiently and ambiguously documented, because America is basically a center-right rather than a center-left nation, because we are the exemplar of democratic humanism rather than colonial aggression, because we believe in free enterprise and economic growth as the antidote and solution to social injustice, because the middle class is weary of the obsession with minorities, the young, and single women, because most of us reject the notion there is a war on women, and because America is governed by the consent of the governed rather than expertise of the elite.

Friday, October 31, 2014

Quote to Note: ACOs Are Just Failed HMOs, but With More Power, WSJ, Letter to Editor, October 31, 2014

“ACOs closely resemble health –maintenance organizations in their basic structure of a lump-sum payment to cover a bundle of services, with financial risk for spending more than this sum.”

“Both create srong disincentives to refer, to hospitalize or so spend money taking care of sick patients."

"Both create strong incentives to cherry-pick health patients. This is how these organizations make money, if successful. Any profit will mostly go to fill corporate coffers and bloated executive paychecks. A few dollars my trickle down to those actually providing care.”

“If HMOs had lived up to their hype, why should we now need ACOs?"

Richard Amerling, MD

President, Assocation of American Physicians and Surgeons, New York

Physician Nightmare over ObamaCare

ObamaCare has turned into a nightmare.

A physician commenting on health exchange health plans

It'e Halloween, four days before midterms, and it’s turning into a nightmare, not as portrayed by horrifying ghosts and goblins, but as realities for practicing physicians, health exchange patients, and ObamaCare partisaans who foresee spooky dangers lurking around the corner and political ghoulies that go bump in the night.

The nightmare? The Medical Group Management Association (MGMA), the largest association representing physician groups, has just announced, based on a survey of its members, that 214,524 physicians, out of 893, 851 practicing physicians(Kaiser Health estimate) will not be accepting patients who enrolled in health exchange plans. The number, 214, 524 is staggering because it represents one-fourth of practicing physicians, 24.0% to be precise, and the U.S. already has physician shortages of 50,000 or more.

Physician Nightmare

To physicians, millions of new health exchange patients represent a potential nightmare.

Why so?

1. Low reimbursements – 40% less than private plans, 20% less than Medicare, on par or less than Medicaid which is less than Medicare.

2. A tsunami of new patients, sicker than most, superimposed on already overloaded and overbooked practices.

3. Health exchange patients, 75% of whom have high deductibles, which low-income patients must pay, leaving doctors stuck with unpaid bills.

4. ObamaCare says patients must be covered for 90 days, insurers will cover for 30 days, leaving the doctors with a collection nightmare, the number one reason doctors and their practice managers give for not accepting these newly government insured patients.

There is another likely reason – physician suspicion and lack of support of ObamaCare. In a recent Physician Foundation survey of 20,000 physicians, 46% gave a ObamaCare a grade of “D” or “F”, and only 4% gave it an “A”.

In any event, ObamaCare is asking doctors to take sicker patients for less with greater risk of not getting paid. The MGMA summarizes the problem, “ Chief among them (reasons for not accepting exchange problems) is the fact that exchange plans are more likely to offer significantly lower reimbursement rates than private market plans, confusion among consumers about the obligations associated with high deductibles, and fear that patients will stop paying premiums and providers will be unable to cover their losses.”

Health Exchange Patient Nightmare

These numbers raises questions: What good is federally-subsidized insurance for patients if too few doctors exist to care for them? What happens if it becomes exceedingly difficult to find doctors? Or if long waiting lines make access to physicians and health care burdensome? There is Medicaid, of course, but the number of doctors accepting Medicaid, is 30% or less, and well below 50% in many regions of the country. And there are community clinics, designed to care for the poor and the uninsured. But for some patients, Medicaid and community clinics smack of social welfare and low-quality care, even if these attitudes are not deserved. And, increasingly, there is more self-care and more direct cash-only care in walk-in clinics and concierge practices.

Political Nightmares

For physicians and politicians there are political nightmares. Physicians will be portrayed as more interested in money than in the health of their patients. And ObamaCare backers, particularly Democrats who voted for the health law without a single Republican vote, will be viewed as supporting an unpopular President and an unpopular law, a law which the latest CBS/WSJ poll indicates only 36% of Americans favor while 55% disapprove.

For the moment at least, four days before the midterms, the Good Ship ObamaCare seems to be listing, in danger of sinking.

Thursday, October 30, 2014

Complexity May Kill ObamaCare

Complexity stalks through the land.


If ObamaCare follows the path of Prohibition , and dies off, or is repealed, it will be because it cannot keep pace with complexity – its inabilities to deal with complexities of regulating the law, enforcing its mandates, collecting its penalties, monitoring its billions of transactions, reducing health care costs, and preventing its frauds and abuses. It will be because ordinary consumers, policy experts, and health care providers are unable to comprehend, coordinate its promises, and to subdue or cope with its complexities.

The Hospital - An Example of Unbridled Complexity

A good example of the difficulties is the modern hospital. Peter F. Drucker (1909-2006) observed, “The hospital is the most complex form of organization ever devised.” It is made up of scores of specialists, each with a different agenda, different skills, different equipment, different jargon; its work forces, its managers and its health professionals, including its work force, 80% of whom are nurses, have different cultures; its customers, physicians and patients, have different sets of expectations, its supply chains are fragmented and it moves to the beat of different sets of regulations – local, state, federal, and professional.

Two Paths around Complexity

As I see it, there are two ways to circumvent or to minimize these complexities.

One is by reducing complexity and the technology that feed it. This can be done by escaping the confines of the hospital, and delivering care outside the hospital in decentralized settings. This is being carried out today in various ways – by setting up independent outpatient facilities, by treating ambulatory patients differently from bed-bound sicker patients, and in the case of physicians, by acting independently of the hospital, and providing direct pay, independent outpatient care free of third party rules and regulations.

Two is by using technology to simplify and consolidate existing technologies. This may seem like a contradiction in terms. But, according to a company called SAP (, it is possible to use technology to simplify technology. SAP is a cloud –based company serving 20,000 organizations and 263, 000 consumers in 190 countries. Its CEO, Bill McDermott says, “We can’t let complexity win.”

I cannot personally vouch for SAP, nor do I have affiliation with it. But I like SAP’s premise: that you can use technology to beat technology. To date, technology has both simplified and complicated our lives. If complexity can be reduced, from a platform in the clouds, as an overall simplifier, and if it can be used to save us from ovwerwhelming complexity for all rather than having complexity kill us all, I am all for it.

In the case of SAP, which just ran a full two page ad in the WSJ, I admire the work of its ad writer.

Here are samples of his/her prose:

• “The exponential proliferation of mobile devices, social media, cloud technologies, and the staggering amount of data they produce have transformed the way we live and work.”

• “Complexity is becoming the most intractable issue of our times, an epidemic of wide-ranging projects, affecting our lives, our work and even our health.”

• “Complexity comes at enormous costs – sixty three percent of executives cite complexity as a primary issue in escalating costs.”

• “If we simplify everything, we can do anything. We just need to run simple...It will generate new opportunities for innovation."

Wednesday, October 29, 2014

Quote to Note: Post-Election Timebombs

“With the midterm elections looming, the White House has delayed controversial decisions and appointments...All of these matters have been high profile and potentially deeply divisive. That is why the White House is postponing any announcements. When the administration finally does speak, it will unleash a political storm, even if Democrats hold the Senate. If Republicans win, those winds will reach hurricane force, since the president will likely try to ram everything through a lame-duck Congress. If that happens, consider boarding up the windows.”

Charles Lipson, Professor of Political Science, University of Chicago, “Obama’s Post-Election Policy Blowout," WSJ, October 29, 2014

ObamaCare’s Delayed Political Time Bombs Set to Explode

Delay is preferable to error.

Letter from Thomas Jefferson to George Washington, 1792

President Obama is a master not only of timely executive action but of timely executive delays.

He has initiated 38 delays at last count. These delays have time fuses, most set to go off just before or just after the midterm elections. These delays of what to do have a strong political flavor rather than a medical coloring, the naming of Ron Klain, a lawyer and political insider, as Ebola “Czar” being the latest example.

The delays include:

• Delay of the employer mandate and $2000 penalties for violating that mandate

• Delays in the individual mandate and paying the $95 penalty for not being insured

• Delays in announcing premium increases in key election states, such as Colorado, Iowa, and Florida

• Delays until after midterms in announcing those millions of health plan cancellations

• A delay in starting that second health care exchange enrollment period until November 15, 2014

• Delays in Medicaid and health exchange expansions, which will expand the national budget deficit

These delays are understandable politically, for their implementation would manage Democrat political prospects.

But like all time bombs, the delays have time fuses that cannot be delayed indefinitely and have an end point.

That end point is the November 4 midterm elections. How to switch from delays to implementation or continuing the delays or even repealing or replacing the health law with a market-based alternative will depend on the outcome of the elections on the national Congressional level and at state houses.